NCC221660_FRO Submitted_20220429

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land -disturbing activity on one or more acres as covered by the Act before this
form and an acceptable erosion and sedimentation control plan have been completed and approved by the
Land Quality Section, N.C. Department of Environment and Natural Resources. (Please type or print and, if
the question is not applicable or the e-mail and/or fax information unavailable, place N/A in the blank.)
Part A.
Project Name The Glen
Location of land -disturbing activity: County Cumberland
Highway/Street NC Highway 87 Latitude 34.953317' N
City or Township Grays Creek
Longitude 78.844751' W
Approximate date land -disturbing activity will commence: November 2021
Purpose of development (residential, commercial, industrial, institutional, etc.): Residential
Total acreage disturbed or uncovered (including off -site borrow and waste areas): 8•9 AC
Amount of fee enclosed: $ 585 . The application fee of $65.00 per acre (rounded
up to the next acre) is assessed without a ceiling amount (Example: a 9-acre application fee is $585).
Has an erosion and sediment control plan been filed? Yes No Enclosed X
Person to contact should erosion and sediment control issues arise during land -disturbing activity:
Name Michael Kaney - MIKA Management E-mail Address [e-mail]
Telephone [phone]
Cell # 919.610.2583 Fax #
Landowner(s) of Record (attach accompanied page to list additional owners):
McKee Homes, LLC
Name
919-909-9632
Telephone
Fax Number
4208 Six Forks Road Suite 810 4208 Six Forks Road Suite 810
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
10. Deed Book No. 1276 Page No. 0014 Provide a copy of the most current deed.
Part B.
Person(s) or firm(s) who are financially responsible for the land -disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
McKee Homes, LLC [e-mail]
Name E-mail Address
4208 Six Forks Road Suite 810 4208 Six Forks Road Suite 810
Current Mailing Address Current Street Address
Raleigh NC 27609 Raleigh NC 27609
City State Zip City State Zip
Telephone [phone] Fax Number

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name
Current Mailing Address
City
Telephone.
E-mail Address
Current Street Address
State Zip City State Zip
Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
Name of Registered Agent E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney -in -fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Patricia Hanchette - McKee Homes President
Type or print name
Signature
Title or Authority
Date
55br za-,A
�, V1')t't•,4 _, a Notary Public of the County of _[P► 4 b-e -1and
State of North Carolina, hereby certify that p hi a �() & appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this 3OX day of i�&4 0 UlS 201
Notary
My commission expires